Clinical, Tricoscopic and Histopathological Findings in Mexican Women with Traction Alopecia

Clinical Dermatology Open Access Journal MEDWIN PUBLISHERS ISSN: 2574-7800 Committed to Create Value for Researchers

Martínez Suarez H1*, Barrera Jacome A2, Ramirez Anaya M3, Barron Hernandez L4 and Morales Miranda AY5 Case Report Volume 5 Issue 3 1Dermatologist, Private practice in Marsu Dermatologia, Mexico Received Date: August 01, 2020 2Dermatopathologist, Deparment of Dermatology, Medical Specialties Unit, University of the Published Date: August 31, 2020 Army and Air Force, Mexico DOI: 10.23880/cdoaj-16000217 3Pediatric dermatologist, General Hospital in Cholula, Mexico 4Dermatologist and Dermatopathologist, Private practice in Puebla, Mexico 5Dermatologist, Deparment of Dermatology, Medical Medical Specialties Unit, University of the Army and Air Force, Mexico

*Corresponding author: Martínez-Suarez Hugo, Dermatologist, Private practice in Marsu Dermatologia, 7 Sur 3118 Chula Vista, Puebla, Zip: 72420, Mexico, Tel: 522225052798; Email: [email protected]

Abstract

Traction alopecia is a common form of hair loss in our population. It is caused by vigorous straightening of the hair causing areas of alopecia. We studied 43 patients diagnosed with traction alopecia from a clinical, tricoscopic and histopathological guide.

great tool in case of diagnostic doubt and provides relevant data related to the evolution time. We believe that the population This disease has a great diversity of clinical findings and can also vary depending on the time of evolution. Histopathology is of should change some hair styles to avoid progression to scarring alopecia.

Keywords: Traction alopecia; Cicatricial alopecia; Marginal alopecia; Trichoscopy; Fringe sign

Introduction and relaxers sustances. In Mexico and Latin America the use of ponytails is widespread. In India and Turkey the use of Traction alopecia is the hair loss caused by continuous, turbans predominates. All are worn for long periods of time vigorous and chronic tightening of the hair. It is a very a day for months or years [1-3]. common disease in African-American women [1]. However, in Latino and Asian populations, it is more frequent than This condition is not new, since there are descriptions previously thought. that identify it for more than 100 years. Trebitsch, a

In each country and region, hair styling and hair to describe it. Similarly, in the last century, some writings alludingdermatologist to this of disease Austrian were origin, published, is apparently with data the firstthat occupational, and religious issues. So, in the black currently continues to be valid. community,care styles arebraids, dictated weaves and and influenced dreadlocks by are sociocultural, used with more frequency, in addition to the use of chemical smoothing

The pathophysiology, it has not been fully identified. Clinical, Tricoscopic and Histopathological Findings in Mexican Women with Traction Alopecia Clin Dermatol J 2 Clinical Dermatology Open Access Journal

The main cause known is the constant and strong pulling projections (frontal and bilateral) and trichoscopic of the or traction of the hair. The hair is damaged when the hair involved areas. We used descriptive statistics. prolonged periods [2]. Results fiber is tightened or stretched throughout its extension, for These different hairstyle styles give rise to diverse Forty-three women, aged 16 to 56 years (mean 33.9 ±) clinical forms. That depend on the evolution time and can be were included. Educational level was: (30%) high school, different in initial and late stages, even in the same patient (30%) bachelor, (27%) middle high school, (9%) primary, [3]. (2%) studies at master’s level. Regarding the occupation we found: (45%) housewives, (16%) nurses, (15%) teachers or The most commun clinical characteristics are: decreased educators, (7%) others (employees, merchants, secretaries), capillary density in the marginal zone of the hair, alopecic (13%) students (Table 1). plaques with the presence of hairs, peri and interfollicular erythema, as well as the described “fringe sign” [4]. The range in the evolution time was from 1 to 35 years, with a mean of 16 years. 16 (37%) of them manifested less than 10 years of evolution and 27 (63%) more than 10 years However, the diagnosis can be a true challenge. Especially, with the problem. if theTheoretically, patient does traction not alopeciaprovide isthe not informationdifficult to identify. about the hairstyle she uses or event deny to use it. It is often Regarding the clinical characteristics, we observed: confused with other hair disorders such as alopecia areata decrease in density or alopecic plaques in 100%, vellous hair characteristics. It is important to mention that this kind of erythema, six cases with peripheral papules and pustules in alopeciaor frontal does fibrosing not provide alopecia much due bothsymptomatology, can share some especially clinical twoin forty-two (5%) patients cases (Table(97%), 2) thirty-five (Figure 1). (79%) with peripheral in its initial stages.

Trichoscopy is an important tool for the diagnosis of hair diseases. And in this condition it becomes essential, because a differentThe tricoscopic level in twenty-two findings were: (51%), peripyllari perifollicular cast in brownthirty- allowed to identify if is an initial or advanced stage. And pigmentfive (79%), in blackthirty-three dots in (77%),twenty-eight empty (53%), follicular broken openings hairs inat allows to identify if it is a scarring or non-scarring alopecia [5]. white dots in eight (19%), pilli torti in three (7%) and trichorhexistwenty-six (60%). nodosa As in extratwo patiens findings, (5%) we (Table observed 3) (Figure irregular 2). Although it is a frequent cause of alopecia, there are few studies about their clinical and trichoscopic characteristics. As mentioned, we carried out a histopathological study Most of the publications are isolated case reports. in some cases with the intention of observing the changes reported in the literature which are dependent on chronicity Material and Methods and thus establish the differences. In the patients with less than ten years we observed: preserved sebaceous glands in Retrospective, descriptive and cross-sectional review. six (75%), a decrease in terminal hairs in all of them (100%), We reviewed the clinical records of patients with traction alopecia diagnosed for two dermatologist in Mexico City and Puebla, México. Along one year (January 2019 to January fibrotic fibrous tracts in three (37%), and sparse lymphocytic 2020). The diagnoses was established with the clinical and inflammationIn chronic in formsseven (87%)we observed (Table 4) decrease (Figure 3).in follicular density in the 88%, as well as an increase in the number of perfomed a biopsy per 4 mm cylinder, carrying out two cuts: follicles in catagen / telogen. Two patients (25%) presented onetrichoscopic longitudinal findings. and transverse, If the diagnosis in both cases was doubtful,staining with we a decrease in the terminal / hairy ratio. Trichomalacia, hematoxylin and eosin. The variables analyzed were: age, pigment casts, or peripheral / intrafollicular hemorrhage occupation, educational level, time of use of hairstyle (years), were not observed in any of the biopsies studied. Alteration also clinical characteristics as erythema, follicular papules, of follicular architecture was observed in two patients follicular pustules, peripillary cylinders, vellous hairs (25%). 100% of the patients presented preserved sebaceous erythema, peripheral brown pigmentation, peripillary casts, tracts (Figure 4). Two patients (25%) presented peripheral blackand alopecicdots, broken patches). hairs Trichoscopic of different findings:lengths and peripheral empty glands, a peripheral inflammatory infiltrate and fibrous follicular openings. Clinical photographs were taken in 3 (12.5%) (Figure 5). fibrosis. Only one patient presented “naked” hair follicles

Martínez Suarez H, et al. Clinical, Tricoscopic and Histopathological Findings in Mexican Copyright© Martínez Suarez H, et al. Women with Traction Alopecia. Clin Dermatol J 2020, 5(3): 000217. 3 Clinical Dermatology Open Access Journal

Figure 1: Women of 44 years old with traction alopecia.

Figure 4:

tracts. Peripheral inflammatory infiltrate and fibrous tracts. peripheral inflammatory infiltrate and fibrous

Figure 2: Girl of 16 years old, with alopecic patches located in bitemporal regions, we can see erythema and perifolcular papules. In the tricoscopy we can observe vellous hair, Black dots, peripheral marron pigmentation and hemorragic crust. Findings suggestive of traction folliculitis. Figure 5: Naked hair follicles.

Level of Number Percentage Occupation Percentage studies Bachelor 13 30% Housewives 45% High school 13 30% Nurses 16% Middle high 11 27% Teachers 15% school Primary 4 9% Students 13% Master level 1 2% Other 7% Table 1: 43 women, aged 16 to 56 years (mean 33.9 ±) and occupation. Figure 3: Preserved sebaceous glands and peripheral

inflammatory infiltrate. Martínez Suarez H, et al. Clinical, Tricoscopic and Histopathological Findings in Mexican Copyright© Martínez Suarez H, et al. Women with Traction Alopecia. Clin Dermatol J 2020, 5(3): 000217. 4 Clinical Dermatology Open Access Journal

Number of Percentage buns and turbans, the most common presentation is a Clinical Characteristics Patientes (%) “marginal pattern”, located in the bitemporal region of the scalp (frontal, temporoparietal and even occipital hairlines) Decrease in density 43 100% [1-3,5]. Vellous hairs 42 97% Peripheral erythema 35 79% In our patients, the most common localization was the Peripheral papules 6 13% bitemporal region, above the preauricular region, followed Pustules 2 5% observed the called “fringe sign” (preservation of numerous Table 2: Clinical characteristics. terminalby the frontal hairs onregion the anteriorand finally border) in the in occipital all the patiens. region. This We

Number of Percentage and its presence should be considered a highly suggestive Tricoscopic findings patients (%) finding is reported in the literature in 85 to 100% of cases Peripyllari cast 35 79% clinicalTraction finding alopecia of AT [4]. has been considered a biphasic disease, Black dots 28 53% with an early (reversible) and a late stage (scarring alopecia). Broken hairs 32 51% Perifollicular brown located in the areas of maximum traction and characterized 33 77% pigment byIn folicular the first papules stage calledand pustules, “traction with folliculitis”, decreased conditioncapillary Empty follicular openings 26 60% density and occasionally alopecic patches [9]. These lesions Irregular white dots 8 19% are caused by irritation and damage secondary to the traction exerted on the hair, which loosens and injures the internal Pilli torti 3 7% and external root sheath of the hair follicle, a process that is Trichorhexis nodosa 2 5% Table 3: accompaniedIt has been by observed mild inflammatory that if the infiltratestraction is [10,11]. very intense, Tricoscopic findings. the follicle can be plucked and the dermal papilla can even <10 years of evolution Number Percentage be extracted, wih permanently damaging and losing of Preserved sebaceous 6 75% the regenerative capacity the hair. This would explain the glands irreversible nature of alopecia in some cases [12]. Decrease in terminal hairs 8 100% 3 37% Traction folliculitis is most often seen in girls and Sparse lymphocytic teenagers. In our patients it was observed in the youngest Fibrotic fibrous tracts 7 87% patients (16 to 22 years old). These patients were generally combed by a third person, the mother or caregiver. Table 4: Findings in patients wiht less than 10 years. inflammation Regarding trichoscopic characteristics, has been Discussion described the presence of broken hair, decreased capillary density and hairiness, peripheral erythema, and peripillary The prevalence of traction alopecia is estimated to range casts [13,14]. Peripillary cast are whitish concretions, that from 1% to 37%. Affects one-third of African American women, and the Hispanic population being the second most distance from the scalp and are considered a product from frequent ethnic group for this type of hair loss [3,6]. In Mexico, thesurround internal the and hair external fiber. Theyroot sheath are usually [15]. locatedThey occur a few in a study on the frequency of types of alopecia reported that 20 to 80% of cases, being more frequent in early and active traction alopecia was the second cause of consultation due to stages and decreasing in the late stage. Its observation hair loss, representing 22% of the sample studied [7]. in the initial consultation is suggestive of the diagnosis and its persistence over time is an indication that traction The location of the patchy areas in traction alopecia continues and therefore alopecia can progress [15,16]. Polat, depends on the hairstyle used. When it is secondary to the et al. studied 25 women with a clinical diagnosis of AT, and use of braids, cornroads, dreadlocks, hair clips or pins, it can reported: appear on any area of the scalp, commonly observed, linear 1. Decreased capillary density, diameter variability and or geometric paths [8]. A horseshoe pattern located in the hairy hair in 100% of their patients, these characteristics were identical in our patients. Yellow dots in 68%, loss extensions has been described. In the case of the ponytails, of follicular openings in 78%, yellow dots and broken occipital region secondary to the use of artificial curtain hair

hair in 68%, black dots and peripheral erythema in 48%, The diagnosis is clinical and requires careful observation peripillary cast in 28% of the clinical characteristics: distribution, shape, presence 2. of the fringe sign and even the hairstyle worn by the patient was the peripillary cylinders in 81%, well above that at the time of the consultation. We propose an easy way to In our study, the most frequent tricoscopic finding identify this disease, we recomended to use the 3T technique was peripheral brown pigmentation (77%), it must be of alopecia: (Traction, Time of evolution and hairstyle Type). considereddescribed by that Polat. all the The patients second had most skin frequent phototypes finding III or IV. Black spots and broken hair were found in 53 and It is important to disclose its clinical and trichoscopic 51% respectively. characteristics among dermatologists, health personnel and even hairdressers in order to carry out a timely detection. As well as massive information and awareness campaigns in depend on the stage of the disease. In early stages, schools and mothers of families in relation to the hairstyle in The histopathological findings of traction alopecia order to prevent this condition. presenting a normal number of hair follicles, an increase inthe the findings count of are catagen similar / telogen to those follicles, of trichotillomania, pigment casts, References trichomalacia, alteration of follicular architecture and peripheral / intrafollicular hemorrhage [4,6]. Being a result 1. Khumalo N, Jessop S, Gumedze F, Ehrlich R (2007) of the mechanical trauma suffered by the hair follicle. The Hairdressing and the prevalence of scalp disease in African adults. Br J Dermatol 157(5): 981-988. described in early stages of the disease [4]. An increase in thepresence number of of a mildcatagen inflammatory / telogen follicles infiltrate and has the also presence been 2. Mualla P (2017) Evaluation of clinical signs and early and segment were observed in our patients. It is believed that if with Fitzpatrick skin type II and III: a single-center, late trichoscopy findings in traction alopecia patients theof lymphohistiocytic hair follicle undergoes inflammatory constant traction infiltrate for ina long the period, upper clinical study. International Journal of Dermatology 56(8): 850–855. alopecia [17]. 3. Khumalo NP, Jessop S, Ehrlich R (2006) Prevalence of chronic peripheral inflammation develops, causing scarring cutaneous adverse effects of hairdressing: a systematic In late stages, the disease shows characteristics of review. Arch 86 Dermatol 142(3): 377. scarring alopecia. Loss of terminal follicles can be observed, 4. Samrao A, Price VH, Zedek D, Mirmirani P (2011) The in the terminal / hairy ratio, due to the fact that the total numberwhich are of replacedhair follicles by fibrous is conserved tracts as[18]. well The as decrease a decrease in alopecia of the 92 marginal hair line. Dermatol Online J the terminal / vellous ratio was observed only in 50% of our 17:“Fringe 1. Sign” - A useful clinical finding in traction patients. At the same time, preservation has been described in the sebaceous glands, although reduced in size, which has 5. Muñoz O, Vaño S (2016) Bitemporal hair loss related to been considered as an indicator of progression to scarring traction alopecia. Dermatology Online Journal 22(9): alopecia. Van Gieson staining and Masson’s trichrome 13030. 6. Billero V, Miteva M (2018) Traction alopecia: the root of hairystaining stems, have in identified which only loss the of hair elastic shaft fibers is observed, and peripheral due to the problema. Clinical and Cosmetic and Investigational thefibrosis destruction respectively. of the Another follicular finding epithelium is the [19].presence This ofdata bare is Dermatology 11: 149-159. observed in the late stage of other scarring alopecia and was 7. Morales-Miranda AY, Morales TML (2018) Most frequent observed in one of our cases [17-19]. alopecias in a third-level dermatological center. Dermatol Rev Mex 62(3): 216-220. Conclusion 8. Haskin A, Aguh K (2016) All hairstyles are not created In the authors experience, traction alopecia is more equal: What the dermatologist needs to know about frequent than reported in the literature, we consider that in black hairstyling practices and the risk of traction most cases it is confused with other causes of alopecia that alopecia. J Am Acad Dermatol 75(3): 606-611.

9. Fox GN, Stausmire JM, Mehregan DR (2007) Traction Althoughare located we in cannot the marginal rule out that line, it such may asbe fibrosingaccompanied frontal by folliculitis: an underreported entity. Cutis 79(1): 26-30. otheralopecia, hair effluvium.disorders. telogen and alopecia areata ofiacea.

10. Dawber RP (1979) Hair casts. Br J Dermatol 100(4): 16. Mathur M, Acharya P, Karki A, Shah J, Nisha KC (2019) 417-421. Tubular Hair Casts in Trichoscopy of Hair and Scalp Disorders. Int J Trichology 11(1): 14-19. 11. Rollins TG (1961) Traction follicultis with hair casts and alopecia. Am J Dis Child 101(5): 639-640. 17. Tanus A, Oliveira CC, Villarreal DJ, Sanchez FA, Dias MF (2015) Black women’s hair: the main scalp dermatoses 12. Sperling LC (1991) Hair anatomy for the clinician. J Am and aesthetic practices in women of African ethnicity. An Acad Dermatol 25(1): 1-17. Bras Dermatol 90(4): 450-65.

13. Miteva M, Tosti A (2012) Hair and scalp dermatoscopy. J 18. Bernárdez C, Molina-Ruiz AM, Requena L (2015) Am Acad Dermatol 67(5): 1040-1048. Histologic features of alopecias-part I: nonscarring 14. Mubki T, Rudnicka L, Olszewska M, Shapiro J (2014) Evaluation and diagnosis of the hair loss patient: part 19. alopecias.Ngwanya RM,Actas Adeola Dermosifiliogr HA, Beach 106(3): RA, Gantsho 158–167. N, Walker II. Trichoscopic and laboratory evaluations. J Am Acad CL, et al. (2019) Reliability of Histopathology for the Dermatol 71(3): 431.e1-431.e11. Early Recognition of Fibrosis in Traction Alopecia: Correlation with Clinical Severity. Dermatopathology 15. Tosti A, Miteva M, Torres F, Vincenzi C, Romanelli P (2010) (Basel) 6(2): 170-181. Hair casts are a dermoscopic clue for the diagnosis of traction alopecia. Br J Dermatol 163(6): 1353-1355.